An ELEMENT to represent a generic clinical finding observation made by a Care Professional, patient, or carer with or without
specific examination. This includes information provided by the patient or carer. A finding on examination can be the interpretation
of a clinical examination of any sort1.
1 NPFIT-NCR-DES-0135.07 NHS Care Record Elements
| Name |
Data type |
Occurs |
Description |
Value Constraints |
|
name
|
SC
|
1..1 |
The name, expressed as a coded value or as plain text, specifies the clinical or administrative concept to which this EHR
node corresponds, as labelled in the EHR system in which it was first committed.
|
| value |
| Literal value(s): FINDING_OBSERVATION_ELEMENT |
|
|
rc_id
|
II
|
1..1 |
The globally-unique identifier by which this node in the EHR hierarchy is referenced in the EHR system to which the data were
first committed. This identifier shall be retained by the EHR Recipient and re-used whenever this RECORD_COMPONENT is subsequently
included in another EHR_EXTRACT.
|
|
|
meaning
|
CD.CV
|
1..1 |
A coded representation of the type of finding. |
|
|
synthesised
|
BL
|
1..1 |
This attribute value shall be TRUE if this RECORD_COMPONENT has been created in order to comply with this standard , but this
point in the EHR hierarchy has no corresponding node in the EHR from which it was extracted.
|
|
|
obs_time
|
IVL_TS
|
0..1 |
The date and time, or interval, of the finding. |
|
|
value
|
ANY
|
1..1 |
An ELEMENT has a single DATA_VALUE containing the value, unless this is indicated as absent by a null_flavour attribute. |
| nullFlavor |
| Literal value(s): NA |
|
